Application for EmploymentAn Equal Opportunity Employer

Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. All information given will be available only to persons who have a "need to know" or as required by law. This company will make reasonable accomodation in the application process, if needed.

Personal Information

First Name*:

Last Name*:

Initial*:

Present Address*:

City*:

State*:

Zip Code*:

Day-time Phone*:

Evening Phone*:

Work Preference

Date Available*:

Kind of Work Desired*:

Salary or Pay You Expect*:

List job benefits, other than wages, you expect or want in order of importance:

Describe your prior experience in the kind of work you want:

Describe any job related formal schooling or training:

List any job related licenses or certificates you may have:

List any job related special skills you may have (typing, machine operation, etc.):

Note: Please indicate conditions you prefer or would accept and other information by entering "yes" or "no" in every blank in the remainder of the sections on this page.

Availability For Work

Which type of employment are you seeking*:
Full-time
Part-time
Temporary or Short Term
Long Term

Shifts you are willing to work*:
Day
Afternoon
Night Shift
Rotating

Will you work daily overtime on occasion if necessary?*:
Yes
No

Will you work extra days in the week if necessary?*:
Yes
No

Present Employment

Do you have to give advance notice to your present employer?*:
Yes
No

Personal

Would you be willing to take a drug/alcohol screening exam before and after employment if requested?*:
Yes
No

Have you missed more than a day or two of work or school for any reason in the past five years?*:
Yes
No

Are you a minor (under 18 years old)?*:
Yes
No

Prior Events

Have you ever worked for or applied for work at this company before?*:
Yes
No

Have you ever been discharged for cause?*:
Yes
No

Have you ever been convicted of a criminal offense?*:
Yes
No

If yes, please explain (A conviction will not necessarily disqualify an applicant.):

Education and Training

Grade and High School

Name of Last School*:

Location*:

Did you graduate?*:
Yes
No

Grade Point Average*:

Special Courses (typing, etc.)*:

What is the last year you completed?*:
6
7
8
9
10
11
12

College or University

Name of School:

Location:

Years Attended:

Major Subject:

Degree Attained:
A.A.
A.S.
B.A.
B.S.

Grade Point Average:

Other (Graduate, Trade School, Correspondence School, etc)

Name of School:

Location:

Length of Course:

Major Subject:

Was Course Completed?
Yes
No

Grade Point Average:

Record of Employment

Current / Most Recent Employer

Name of Employer*:

Address*:

City*:

State*:

Zip*:

Phone*:

List the jobs you held, duties performed, skills used or learned, advancements or promotions*:

Start Date*:

End Date*:

Starting Rate of Pay*:

Ending Rate of Pay*:

Supervisor's Name*:

Type of Business*:

What did you like about this job?*:

What did you dislike about this job?*:

Why did you leave?*:

Reference Check Contact*:

Next Previous Employer

Name of Employer*:

Address*:

City*:

State*:

Zip*:

Phone*:

List the jobs you held, duties performed, skills used or learned, advancements or promotions*:

Start Date*:

End Date*:

Starting Rate of Pay*:

Ending Rate of Pay*:

Supervisor's Name*:

Type of Business*:

What did you like about this job?*:

What did you dislike about this job?*:

Why did you leave?*:

Reference Check Contact*:

Next Previous Employer

Name of Employer*:

Address*:

City*:

State*:

Zip*:

Phone*:

List the jobs you held, duties performed, skills used or learned, advancements or promotions*:

Start Date*:

End Date*:

Starting Rate of Pay*:

Ending Rate of Pay*:

Supervisor's Name*:

Type of Business*:

What did you like about this job?*:

What did you dislike about this job?*:

Why did you leave?*:

Reference Check Contact*:

List other positions and periods of unemployment*:

Certificate of Applicant

Read carefully before signing

All information provided by me is true and correct to the best of my knowledge. I understand any omissions or misrepresentations on this application may result in rejection, or if employed, may be cause for subsequent dismissal. I hereby authorize an former employer, person, firm or corporation listed herein including this company to answer any and all questions and agree to hold all persons harmless for giving any and all truthful information within their knowledge or records. I understand this is a preliminary application and not a contract to employ me. I understand and agree that any employment I may obtain is for no definite period of time. If employed, I agree to comply with all rules of the company as a condition of continued employment.

This Employment Application is used to notify me that the nature and scope of an investigation, if one is conducted, could include such general identification information as residence verification, and, as applicable, information concerning my employment, education, general reputation, character, personal characteristics, and habits, and that such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employers, financial sources, and custodians of official records. Only job-related information developed from such a report will be considered in evaluating my employment application or continued employment. I hereby authorize these persons, companies, organizations or corporations to answer all questions or release any information regarding the items listed in this paragraph. I hereby release them from any liability and hold them harmless from any claim for releasing any truthful information within their knowledge and/or records.

I authorize the company to release to any person, firm, entity, or organization with which I may seek employment in the future, any truthful information concerning my work experience with the company. I hereby release and hold the company harmless from any claim for releasing any truthful information within its knowledge and/or records.